CCI Registered Nursing Services
Chronic Care Innovations CCM and RPM Programs
Chronic Care Management (CCM) services consist of outreach by Registered Nurses once per calendar month, to patients with the required elements:
Two (2) or more Chronic conditions expected to last at least 12 months, or until the death of the patient. The conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Patients must have seen their PCP within the last 12 months, or an initiating visit is required prior to starting CCM.
Registered Nursing CCM services include:
New patient contact and enrollment with complete documentation including obtaining patient consent.
Providing education to patients about comprehensive CCM program.
Providing education to patients about their chronic conditions and management of conditions.
Comprehensive care plan established with patient input and agreement. Care plans are implemented, revised, and monitored by Registered Nurse. and updated monthly and as needed.
Designated Registered Nurses provides continuity of care to patients while providing access to care.
Coordination of care and sharing of patient information with the medical practice.
Complete documentation of CCM event accessible to medical practice.
Remote Patient Monitoring (RPM) services consist of outreach by Registered Nurses for patients with the required elements:
Patients have chronic, high-risk or post-discharge conditions and can use or be assisted with RPM devices.
Patients are motivated and capable of engaging with the program.
Patients’ needs meet medical necessity and regulatory requirements for reimbursement.
Registered Nursing RPM services include:
Providing education to patients about comprehensive RPM program.
Monthly telephonic Remote Patient Monitoring includes review of data trends, interventions and escalation when indicated.
Providing education to patients about their chronic conditions and management of conditions.
Communication and coordination of care with patient’s medical practice including documentation of all patient interactions and practice communications.
Complete documentation of CCM event accessible to medical practice.
